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:I APPLICATION FOR PERMIT 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--8420 P O 60% 2009, STOCKTON, CA 95201 PFRMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete is Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. � � ��--- Job Address City 1 Lot Size/Acreage /n7r Owner's Name 'r'C� _ Address P10 . Phone -5_2 — ` tl Corttractof Address pmd License No. Phone_ -0_3_l TYPE OF WELL/PUMP: i NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION E SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATICINSS Ll Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excav tion 1 I_ Dia. af'Well Casing ' F-1 Domestic/ IKGravel Pack ❑ Tracy Type of Casing Specifications Il PublicAX9,Approx. her 1-1 Delta Depth of Grout Seal Type of Grout � I Irrigation Depth JI Eastern Surface Seal Installed by Repair Work pone 0 Type of Pump H,P. _ State Work Done_ p Well Destruction ❑ Well Diameter Sealing Material & Depth } Depth: Filler Material b Depth i TYPE OF SEPTIC WOr t:.� NEW,INSTALLATION [ I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence Commercial— Other t Number of living units: Number of bedrooms ` i Character of soil to a depth of 3 feet: _Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Cl Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE D No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f t SEEPAGE PITS 11 Depth Size Number SUMPS Ci Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p y parsons subject to workman's compensa- tion laws of Californi The applicant t call for all required inspectio s. Complete dra on reverse side, r ,. „.... ills: � � Signed a N t��j�' � Date: DEPARTMENT USE ONLY Application Accepted by •'� Date - Area Pit 009 out napection by Date��s Final Inspection by Data I Additional Comments;& � Applicant Return copies to: San Joaquin County Public Health �h i a Services, Environmental Health Permit/Services ry�ly� 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 INFO AMOUNT DUEUNT REMITTED CA$H RECEIVED BY DATE PERMIT'N0. + EH13.24(HEV.Iinsl cp�� 4 / U EH 74-2e t � ✓ l k g f L